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Rather than emulate Ofsted’s culture of fear, the UK care regulator must engage clinicians to improve standards

BMJ 2013; 347 doi: (Published 18 July 2013) Cite this as: BMJ 2013;347:f4611
  1. Billy Boland, consultant psychiatrist and lead doctor in safeguarding adults, Hertfordshire Partnership NHS Foundation Trust, St Albans AL3 5TL, UK
  1. billy.boland{at}

The Care Quality Commission should listen to Robert Francis, says Billy Boland. Cultural, not structural, change is needed, and to improve quality and safety the regulator must engage with doctors and nurses, who identify most cases of abuse and neglect

On 21 June the health secretary Jeremy Hunt announced a further £40m (€46m; $26m) for the Care Quality Commission (CQC) after revelations of an internal cover-up of its failure to monitor poor performance in Morecambe Bay Hospital.1 Hunt said on BBC Radio 4’s Today programme that it was “beyond belief” that the regulator that was supposed to “speak out” about bad practice had behaved in such a way. The additional money is intended to improve the quality of inspection and to give Ofsted style assurance to patients and the public, Hunt said.

The Office for Standards in Education, Children’s Services and Skills (Ofsted), established in 1992, carried out over 30 000 inspections in 2011-2 and has an annual budget of £165m.2 In contrast the CQC spent £60.9m in the same year and carried out 17 000 site visits.3 Ofsted’s grander budget reflects its greater maturity, with Ofsted being almost 20 years senior to the CQC. The additional funding has in part paid for in-depth assessments done by “specialists” familiar with schools and the education system.

Hunt’s vision for investment is to encourage the CQC to highlight excellent practice as well as identify bad practice and to improve standards among care providers by moving away from “generalist” and towards much more thorough “specialist” inspections. But all this talk of regulation and inspection overlooks one of the biggest resources for improving quality and spreading good practice—clinicians.

The dust is only just beginning to settle after the Francis report on the scandal of poor care at Mid Staffordshire NHS Foundation Trust, but are the lessons being learnt? Francis was clear that structural change was not required to prevent another such tragedy, but a change in culture was.4 Although the public inquiry recognised the need for a care regulator, it also emphasised the need for “professionally endorsed means” and an atmosphere of “openness, transparency and candour.”

But an obsession with regulation alone cannot bring about the changes that are needed and will do little to promote the culture Francis describes. Hunt has argued that “clinically led” inspection will do a better job of identifying problems in care, but, by discussing regulation without discussing clinicians and their work, he is suggesting that regulation is all that is necessary to protect patients. The everyday, mundane reality is that it is clinical staff who uphold standards of quality and safety.

It is the responsibility of clinicians to help safeguard the needs of patients and protect those at risk of harm, including neglect in care.5 Currently, professionals who work with patients identify the majority of cases of harm or risk of harm in adults, and in 2010-11, health and social care staff referred 66% of the 106 165 adults referred to adult social care safeguarding teams that year (70 120 referrals), whereas the CQC referred less than 3%.6

Beefing up external regulatory activity could be counterproductive. By its nature, inspection and monitoring can only ever appraise healthcare providers from the perspective of an outsider. One-off inspections are met with best behaviour, and those under scrutiny will behave as expected. This can present a sanitised view of an organisation.

Our complex, changing healthcare environments require clinicians that are intelligent, adaptive, and observant. Doctors and nurses work together in close quarters, delivering care as teams and learning from each other. Our professional cultures, captured by regulators such as the General Medical Council,7 require that we develop ourselves and speak out when things go wrong. The NHS increasingly recognises the importance of clinical leadership and engagement in patient safety.8

It is the eyes and ears of doctors, nurses, and social workers that are most likely to identify abuse and harm in vulnerable patients. To tackle poor care we need a balance between external regulation and internal practice. Good care and treatment are best achieved with a highly trained, highly motivated workforce. Patients should be the primary concern, and we need a culture in which it is easy to speak out. Ratcheting up regulatory intensity without promoting positive cultural change risks sending the wrong message to healthcare staff.

If the CQC is to be reinvented in the image of Ofsted, it should seek to learn a sobering lesson from its regulatory sibling. Michael Gove, secretary of state for education, was in the headlines recently after being challenged by a head teacher over a “culture of fear” created by Ofsted.9 Hunt must highlight the need for the CQC, commissioners, and providers to collaborate with clinicians if he is seeking a real improvement in patient safety.


Cite this as: BMJ 2013;347:f4611


  • Competing interests: I have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.


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